A multisociety Delphi consensus statement on new fatty liver disease nomenclature

Exploring the potential of large language models in identifying metabolic dysfunction-associated steatotic liver disease: A comparative study of non-invasive tests and artificial intelligence-generated responses

BACKGROUND AND AIMS

This study sought to assess the capabilities of large language models (LLMs) in identifying clinically significant metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

We included individuals from NHANES 2017-2018. The validity and reliability of MASLD diagnosis by GPT-3.5 and GPT-4 were quantitatively examined and compared with those of the Fatty Liver Index (FLI) and United States FLI (USFLI). A receiver operating characteristic curve was conducted to assess the accuracy of MASLD diagnosis via different scoring systems. Additionally, GPT-4V's potential in clinical diagnosis using ultrasound images from MASLD patients was evaluated to provide assessments of LLM capabilities in both textual and visual data interpretation.

RESULTS

GPT-4 demonstrated comparable performance in MASLD diagnosis to FLI and USFLI with the AUROC values of .831 (95% CI .796-.867), .817 (95% CI .797-.837) and .827 (95% CI .807-.848), respectively. GPT-4 exhibited a trend of enhanced accuracy, clinical relevance and efficiency compared to GPT-3.5 based on clinician evaluation. Additionally, Pearson's r values between GPT-4 and FLI, as well as USFLI, were .718 and .695, respectively, indicating robust and moderate correlations. Moreover, GPT-4V showed potential in understanding characteristics from hepatic ultrasound imaging but exhibited limited interpretive accuracy in diagnosing MASLD compared to skilled radiologists.

CONCLUSIONS

GPT-4 achieved performance comparable to traditional risk scores in diagnosing MASLD and exhibited improved convenience, versatility and the capacity to offer user-friendly outputs. The integration of GPT-4V highlights the capacities of LLMs in handling both textual and visual medical data, reinforcing their expansive utility in healthcare practice.

Role of metabolic dysfunction-associated steatotic liver disease and of its genetics on kidney function in childhood obesity

OBJECTIVES

Evidence linked metabolic associated steatotic liver disease (MASLD) to kidney damage with the potential contribution of the I148M variant of the Patatin-like phospholipase containing domain 3 (PNPLA3) gene. We aimed at investigating the relationship of MASLD and of its genetics with kidney function in children with obesity.

METHODS

A comprehensive evaluation including genotyping for the I148M PNPLA3 polymorphism was performed in 1037 children with obesity. Fatty liver (FL) was assessed by liver ultrasound. According to MASLD criteria, subjects with obesity but without FL were included in group 1, while patients with obesity and FL (encompassing one MASLD criterion) were clustered into group 2. Group 3 included patients with obesity, FL, and metabolic dysregulation (encompassing >1 MASLD criterion).

RESULTS

Alanine transaminase levels significantly increased while estimated glomerular filtration rate (eGFR) significantly reduced from group 1 to 3. Group 3 showed a higher percentage of carriers of the I148M allele of the PNPLA3 gene compared to other groups (p < 0.0001). Carriers of group 2 and of group 3 showed reduced eGFR levels than noncarriers of group 2 (p = 0.04) and of group 3 (p = 0.02), respectively. A general linear model for eGFR variance in the study population showed an inverse association of eGFR with both MASLD and PNPLA3 genotypes (p = 0.011 and p = 0.02, respectively). An inverse association of eGFR with MASLD was also confirmed only in carriers (p = 0.006).

CONCLUSIONS

The coexistence of more than 1 MASLD criterion in children with obesity seems to adversely affect kidney function. The PNPLA3 I148M allele further impacts on this association.

Decorin alleviates non-alcoholic fatty liver disease in rats with polycystic ovary syndrome

Endocrine multisystem defect polycystic ovary syndrome (PCOS) causes hyperandrogenism and infertility. Half of PCOS women have (non-alcoholic fatty liver disease) NAFLD, which increases metabolic disease risk. We tested decorin's effect on NAFLD and related processes in PCOS. NAFLD+PCOS, PCOS+decorin, and control rats were studied. Decorin was evaluated on NAFLD/PCOS rats. Test group rats received HF for eight weeks to generate NAFLD. The rats got 1 mg/kg letrozole orally daily for 21 days to diagnosis PCOS. Afterward, rats got injectable decorin for 14 days. Body weight, liver weight, liver coefficient Abdominal Circumference (AC) and body mass index (BMI) were determined. Blood triglycerides (TG), total cholesterol, LDL-c, AST, and glucose were measured. The insulin, testosterone, estrogen, LH, and FSH were measured by ELISA. GPx, SOD, MDA, TNF-, and Caspase-3 liver immunohistochemistry were evaluated. NAFLD liver tissues in PCOS models showed biochemical and histological alterations. NAFLD+PCOS raised BMI, AC, liver weight, and coefficient. Blood glucose, insulin resistance, TG, ALT, and AST increased. Lipid abnormalities (TG, cholesterol, LDL-c, and HDL-c), oxidative stress markers (MDA, SOD, and GPx), and liver dysfunction were found. Low serum E2 and high T supported PCO. Decorin reduced model rat BMI, liver weight, coefficient, insulin resistance, TG, ALT, and AST. It reduced liver inflammation, improved liver extract lipids, and normalized MDA, SOD, and GPx. In the model group, decorin lowered serum T, E2, LH, caspase 3, and TNF-alpha. Decorating improved NAFLD/PCOS group liver histology and function. Decorin reduces hepatosteatosis by reducing liver inflammation, oxidative stress, and dyslipidemia.

Benefits and disadvantages of combination therapy with imeglimin and metformin in patients with type 2 diabetes

BACKGROUND

We retrospectively examined the benefits and disadvantages of adding imeglimin to metformin therapy in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Ninety-four patients with type 2 diabetes who had been administered imeglimin were included in the safety analysis set (SAS). Sixty-four patients who had been treated with imeglimin for over 6 months were included in the full analysis set (FAS). The primary outcome was the change in HbA1c levels in the FAS. The secondary outcomes were gastrointestinal adverse events (AEs) in the SAS and changes in body weight and FIB-4 in theFAS.

RESULTS

In the SAS, gastrointestinal AEs occurred in 15 of 40 (38%) metformin users and 6 of 54 (11%) non-users. In the FAS, HbA1c levels were significantly reduced in both metformin users (n = 27, baseline, 8.5 ± 1.1%;6 months, 7.7 ± 1.2%) and non-users (n = 37, baseline, 8.0 ± 0.9%; 6 months,7.4 ± 0.9%). While body weight (from 72.0 ± 20.5 kg to 70.9 ± 20.8 kg) and FIB-4 (from 1.27 ± 0.57 to 1.17 ± 0.49) significantly decreased in metformin users, they did not significantly differ in non-users.

CONCLUSIONS

Adding imeglimin to metformin therapy demonstrated favorable reductions in HbA1c, body weight, and FIB-4 in patients with type 2 diabetes, although it was associated with the incidence of gastrointestinal AEs.

TRIAL REGISTRATION

UMIN000055241.

Risk of de novo HCC in patients with MASLD following direct-acting antiviral-induced cure of HCV infection

BACKGROUND & AIMS

Data are limited on the risk of de novo hepatocellular carcinoma (HCC) in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) who have achieved sustained virologic response at off-treatment week 12 (SVR12) using direct-acting antivirals (DAAs) for HCV.

METHODS

A total of 1,598 eligible patients received biannual alpha-fetoprotein (AFP) and liver imaging surveillance to detect de novo HCC after achieving SVR12. MASLD was defined as presence of controlled attenuation parameter (CAP) ≥248 dB/m and ≥1 cardiometabolic risk factor (CMRF). Cumulative HCC incidence was compared between patients with/without MASLD. We built univariable and multivariable Cox proportional hazards models to evaluate factors associated with HCC. Sensitivity analysis was performed using the Fine-Gray subdistribution hazards model. Additionally, we evaluated the mediation effect of MASLD on CMRFs and of CMRFs on MASLD for HCC using mediation analysis with bootstrapping.

RESULTS

The incidence rate of HCC was 1.44 per 100 person-years of follow-up (95% CI 1.19-1.74). Patients with MASLD had a higher cumulative HCC incidence than those without MASLD (log-rank test, p <0.001). Multivariable Cox regression analysis revealed that in addition to age, sex, liver stiffness measurement, platelet count, and AFP, MASLD (adjusted hazard ratio 2.07; 95% CI 1.36-3.16; p <0.001) was independently associated with HCC. This finding was confirmed by the Fine-Gray model, which showed a subdistribution hazard ratio of 2.07 (95% CI 1.34-3.19, p <0.001) for MASLD. MASLD significantly mediated CMRFs for HCC development.

CONCLUSION

After achieving SVR12, patients with MASLD exhibited an increased HCC risk compared to those without MASLD. Vigilant HCC surveillance and control of CMRFs to mitigate the effect of MASLD on HCC remain crucial for this population.

IMPACT AND IMPLICATIONS

The risk of de novo hepatocellular carcinoma (HCC) among patients with metabolic dysfunction-associated steatotic liver disease (MASLD) who have attained a sustained virologic response to direct-acting antivirals remains to be confirmed. In this study, recruiting 1,598 patients in Taiwan, individuals with MASLD had an approximately two-fold increased risk of de novo HCC compared to those without MASLD after achieving a sustained virologic response. MASLD significantly mediated cardiometabolic risk factors for HCC development. Our findings underscore the critical importance of pharmacological interventions and proactive lifestyle modifications to control cardiometabolic risk factors in patients with MASLD, as well as the need for vigilant HCC surveillance to ensure favorable outcomes following HCV eradication.

Non-invasive tests for fibrotic MASH for reducing screen failure in therapeutic trials

BACKGROUND & AIMS

Therapeutic trials in metabolic dysfunction-associated steatohepatitis (MASH) are hampered by a high 70-80% screen failure rate mostly because of the absence of fibrotic MASH on baseline liver biopsies, underscoring the need for better selection of candidates. We compared the performance of eight non-invasive tests, designed or not for the diagnosis of fibrotic MASH.

METHODS

A total of 1,005 patients with histologically proven MASLD were included in five tertiary care centers. Three non-invasive tests developed for fibrotic MASH were evaluated: the simple blood test Fibrotic NASH Index (FNI), the specialized blood test MACK-3, and the elastography-based test FAST. Five non-invasive tests recommended for advanced fibrosis were evaluated as well: the simple blood test FIB-4, the specialized blood tests FibroTest and Enhanced Liver Fibrosis test (ELF™), and the elastography-based tests FibroScan and Agile3+. Fibrotic MASH was defined as MASH with MASLD activity score ≥4 and fibrosis score F ≥2.

RESULTS

Among simple blood tests (n = 1,005), FNI had a significantly higher area under the receiver operating characteristic (AUROC) for fibrotic MASH than FIB-4 (0.709 [0.677-0.741] vs. 0.662 [0.628-0.695], p = 0.019). Among elastography-based tests (n = 817), FAST had a significantly higher AUROC (0.774 [0.743-0.806]) than FibroScan (0.728 [0.694-0.763], p = 0.013) and Agile3+ (0.708 [0.672-0.744], p = 0.004). Among specialized blood tests (n = 545), MACK-3 had a significantly higher AUROC (0.772 [0.734-0.811]) than FibroTest (0.615 [0.568-0.663], p <0.001) and ELF (0.700 [0.656-0.744], p = 0.028). Sequential combination (FAST then Agile3+; MACK-3 then ELF) identified a subset including one-third of patients in whom the false-positive rate was only 30%.

CONCLUSIONS

Sequential combinations using first-line tests designed for fibrotic MASH improves the identification of candidates for MASH therapeutic trials.

IMPACT AND IMPLICATIONS

Drug development in metabolic dysfunction-associated steatohepatitis (MASH) is hampered by a high screen failure rate, one of the main reasons being the absence of MASH and significant fibrosis (fibrotic MASH) on the baseline liver biopsy, a key inclusion criterion in MASH therapeutic trials. Non-invasive tests represent an attractive opportunity to better select candidates for these trials, but most of them have been developed for advanced fibrosis and the new tests designed for the diagnosis of fibrotic MASH remain poorly validated. In this work, we demonstrate that the tests specifically designed for fibrotic MASH are more accurate for this diagnostic target than the tests currently recommended and initially developed for advanced fibrosis. We propose sequential combinations that will facilitate the identification of patients with fibrotic MASH in need of treatment, and their inclusion in MASH therapeutic trials.

Liver-specific inactivation of Cideb improves metabolic profiles and ameliorates steatohepatitis and fibrosis in animal models for MASH

Germline mutations of CIDEB, a lipid droplets (LDs)-associated protein, confer protection against various liver diseases in humans. It remains to be determined whether liver-specific inhibition of CIDEB will bring clinical benefits. We aim to establish pharmacological proof of concept by testing GalNAc-conjugated Cideb surrogate siRNAs in respective animal models of obesity and MASH and to develop siRNA drug candidates for clinical investigations. Surrogate siRNAs targeting mouse Cideb were designed and evaluated via a panel of assays. Concurrently, humanized CIDEB knock-in mice were generated as a research tool to facilitate human therapeutic siRNA discovery. In vivo administration of the surrogate siRNAs was conducted in the diet-induced obesity (DIO) model and CDAA-HFD model of MASH. In the DIO model, Cideb knockdown led to significant reductions of serum total cholesterol (TC) and triglyceride (TG) levels, a significant decrease in hepatic macro-steatosis and notable weight loss. In the CDAA-HFD model, Cideb siRNA treatment significantly reduced liver TC and TG levels. Furthermore, remarkable reductions of hepatic steatosis and the composite NAS score were observed with a concomitant amelioration of liver fibrosis. Transcriptome analyses revealed that integrin pathways may contribute to the major pharmacological activities upon Cideb inactivation beyond lipid metabolism. CIDEB exhibits significant potential as a therapeutic target for the treatment of MASH. Liver-targeting siRNA candidates are under development for therapeutic hypothesis testing in humans.

Reducing complications of metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

Complications from metabolic dysfunction-associated steatotic liver disease (MASLD) include liver-related and extrahepatic complications, and the all-cause mortality rate is significantly higher in patients with MASLD than in those without MASLD.

AREAS COVERED

We review the complications of MASLD and their management based on the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD) guidelines as well as medical papers. For the papers, we focused on studies referenced in the EASL and AASLD guidelines. Additionally, a search was conducted in PubMed to gather relevant literature.

EXPERT OPINION

Identifying and managing MASLD early, before it progresses to cirrhosis, is crucial to reducing mortality rates, and collaboration among healthcare professionals, including dietitians, nurses, and physical therapists, is vital for comprehensive management. There is active development of new drugs for MASLD, and we hope that new treatments will be developed soon.

Role of gliflozins on hepatocellular carcinoma progression: a systematic synthesis of preclinical and clinical evidence

INTRODUCTION

The risk of HCC is twice as high in diabetic patients compared to non-diabetic ones, suggesting that diabetes advances carcinogenesis in the liver through a variety of mechanisms. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to improve liver outcomes, emerging as promising agents to treat hepatocellular carcinoma (HCC) in patients with type 2 diabetes mellitus (T2DM).

METHODS

We searched PubMed and Scopus databases for articles presenting an association between SGLT2is and HCC to explore the putative mechanisms of action underlying the anti-proliferative activity of SGLT2is.

RESULTS

A total of 24 articles were selected for inclusion, of which 14 were preclinical and 10 were clinical. Preclinical studies were mainly focused on canagliflozin, used alone or in combination with other drugs.

CONCLUSIONS

Overall, canagliflozin had a negative effect on HCC cell proliferation by interfering with glucose-dependent and independent metabolic pathways, negatively impacting angiogenesis, and inducing apoptosis in in-vitro cell models. In-vivo, a protective effect on hepatic steatosis and fibrosis and HCC development has been reported. Human studies showed a lower risk of developing HCC in patients on SGLT2is. However, this is supported by retrospective cohort studies. Clinical trials are needed to confirm the causal relationship between SGLT2i administration and HCC development.

Global Burden of Major Chronic Liver Diseases in 2021

BACKGROUND

This study utilised the Global Burden of Disease data (2010-2021) to analyse the rates and trends in point prevalence, annual incidence and years lived with disability (YLDs) for major chronic liver diseases, such as hepatitis B, hepatitis C, metabolic dysfunction-associated liver disease, cirrhosis and other chronic liver diseases.

METHODS

Age-standardised rates per 100,000 population for prevalence, annual incidence and YLDs were compared across regions and countries, as well as the socio-demographic index (SDI). Trends were expressed as percentage changes (PC) and estimates were reported with uncertainty intervals (UI).

RESULTS

Globally, in 2021, the age-standardised rates per 100,000 population for the prevalence of hepatitis B, hepatitis C, MASLD and cirrhosis and other chronic liver diseases were 3583.6 (95%UI 3293.6-3887.7), 1717.8 (1385.5-2075.3), 15018.1 (13756.5-16361.4) and 20302.6 (18845.2-21791.9) respectively. From 2010 to 2021, the PC in age-standardised prevalence rates were-20.4% for hepatitis B, -5.1% for hepatitis C, +11.2% for MASLD and + 2.6% for cirrhosis and other chronic liver diseases. Over the same period, the PC in age-standardized incidence rates were -24.7%, -6.8%, +3.2%, and +3.0%, respectively. Generally, negative associations, but with fluctuations, were found between age-standardised prevalence rates for hepatitis B, hepatitis C, cirrhosis and other chronic liver diseases and the SDI at a global level. However, MASLD prevalence peaked at moderate SDI levels.

CONCLUSIONS

The global burden of chronic liver diseases remains substantial. Hepatitis B and C have decreased in prevalence and incidence in the last decade, while MASLD, cirrhosis and other chronic liver diseases have increased, necessitating targeted public health strategies and resource allocation.

DRD2-Mediated AMPK Ubiquitination Regulates the Occurrence of Hepatic Steatosis

BACKGROUND & AIMS

G protein-coupled receptors (GPCRs) are important potential drug targets for the treatment of metabolic disorders. The D2 dopamine receptor (DRD2), a GPCR receptor, is a member of the dopamine receptor family. However, the role of DRD2 in regulating lipid metabolism, especially in hepatic steatosis, is unclear.

METHODS

Eight-week male mice were fed HFHC/MCD to induce the MASH model. AAV2/8 containing the TBG promoter was used to knock down and overexpress DRD2 in mouse liver. Co-immunoprecipitation, Western lotting, immunofluorescence, and immunohistochemistry were used to investigate the mechanisms and screen DRD2 antagonists.

RESULTS

The study found that activation of PKC leads to the elevation and internalisation of DRD2 in a high-fat environment. Knockdown of DRD2 in mouse liver can effectively interfere with the progression of MASH, while overexpression of DRD2 significantly aggravates the process of MASH. The study on the mechanism of DRD2 regulating lipid metabolism found that the internalisation of DRD2 could lead to dephosphorylation of pAKT (T308) by binding to β-arrestin2 and pAKT, thereby inducing ubiquitin-dependent degradation of AMPK and exacerbating steatosis. L-741626, a DRD2 antagonist, was found to interfere with the internalisation of DRD2 in a high-fat environment. It has been shown that L-741626 can treat MASH by regulating the AKT-AMPK signalling axis in vitro and in vivo.

CONCLUSIONS

In conclusion, this study demonstrated that internalisation of DRD2 in a high-fat environment aggravated MASH progression through the AKT-AMPK signalling axis. Furthermore, L-741626, as a DRD2 antagonist, has the potential to treat MASH.

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) Impacts Long-Term Outcomes After Curative-Intent Surgery for Hepatocellular Carcinoma

BACKGROUND

Curative surgery for hepatocellular carcinoma (HCC) includes liver resection (LR) and orthotopic liver transplantation (OLT). Due to the obesity epidemic, metabolic dysfunction-associated steatotic liver disease (MASLD) is a frequent HCC aetiology that often coincides with increased alcohol consumption, termed MetALD, or even alcohol-associated liver disease (ALD).

METHODS

Patients undergoing LR or OLT for HCC at Charité-Universitätsmedizin Berlin (2010-2020) were included in this retrospective cohort study investigating disease aetiology, time to recurrence (TTR), overall survival (OS) and CT-based body composition.

RESULTS

Out of 579 patients with HCC, 417 underwent LR and 162 OLT. Tumour aetiologies were viral n = 191 (33.0%), MASLD n = 158 (27.3%), MetALD n = 51 (8.8%), ALD n = 68 (11.7%) and other/cryptogenic n = 111 (19.2%). Patients with MASLD and MetALD had more intramuscular (p < 0.001, p = 0.015) and visceral fat (both p < 0.001) than patients with non-metabolic dysfunction aetiologies. Patients with MASLD-HCC had comparable TTR (median 26 months, [95% CI: 23-31] vs. 30 months [95% CI: 4-57], p = 0.425) but shorter OS than patients with other HCC aetiologies (63 months [95% CI: 42-84] vs. 80 months [95% CI: 60-100], hazard ratio: 1.53 [95% CI: 1.050-2.229], p = 0.026) after LR. Multivariate analysis confirmed MASLD aetiology, portal vein thrombosis and MELD score ≥ 10 as independent prognostic factors for OS in LR (adjusted p = 0.021,p < 0.001,p = 0.003), even after excluding in-hospital mortality (adjusted p = 0.016,p = 0.002,p = 0.002). Causes of death were similar in MASLD and non-MASLD aetiology.

CONCLUSIONS

Patients with HCC undergoing LR and meeting the new MASLD criteria have significantly shorter OS. This study provides empirical prognostic evidence for the novel MASLD/MetALD classification in a large European cohort of patients undergoing curative-intent HCC therapy.

MASLD, At-Risk MASH and Increased Liver Stiffness Are Associated With Young Adulthood Obesity Without Residual Risk After Losing Obesity

BACKGROUND

Obesity can result in persistent metabolic changes despite weight loss, which may affect liver health. We aimed to investigate associations between young adulthood obesity and metabolic dysfunction-associated steatotic liver disease (MASLD), at-risk steatohepatitis and increased liver stiffness measurement (LSM) in a general population setting.

METHODS

We studied NHANES 2017-2020 community-dwelling participants aged > 40 years with BMI ≥ 18.5 and no heart failure. Weight at age 25 was obtained through questionnaires and compared to current weight. Assessment included controlled attenuation parameter (CAP) and LSM. Associations between obesity status change with MASLD or at-risk metabolic dysfunction-associated steatohepatitis (MASH) and increased LSM were investigated and adjusted for demographics and metabolic health.

RESULTS

The cohort comprised 4,580 participants (57% stable non-obesity, 33% gained obesity, 2% lost obesity and 8% stable obesity). Compared to stable no-obesity, stable obesity was strongly associated with MASLD (odds ratio [OR]: 5.47, 95% confidence interval [95%CI]: 3.97-7.66) as was gained obesity (OR: 4.68, 95% CI: 3.93-5.59), whereas no increased risk was demonstrated for lost obesity (OR: 1.26, 95% CI: 0.76-2.10). Similar associations for stable obesity and gained obesity with at-risk MASH and LSM ≥ 8 kPa were demonstrated. No residual risk was found for lost obesity (MASH-OR: 1.05 95% CI: 0.36-2.49; LSM ≥ 8 kPa-OR: 0.85, 95% CI: 0.29-1.97). Results were consistent in sensitivity analysis where obesity change was calculated over the past 10 years and weight change was stratified in normal weight/overweight/obesity.

CONCLUSION

Young adulthood obesity is an important risk factor for MASLD, at-risk MASH and increased LSM among the general population aged 40-80 years. Losing obesity resulted in normalisation of odds for MASLD, at-risk MASH and increased LSM. These findings underline the importance of preventing and treating young adulthood obesity to maintain liver health.

Examining the link between 179 lipid species and 7 diseases using genetic predictors

BACKGROUND

Genome-wide association studies of lipid species have identified several loci shared with various diseases, however, the relationship between lipid species and disease risk remains poorly understood. Here we investigated whether the plasma levels of lipid species are causally linked to disease risk.

METHODS

We built genetic predictors of 179 lipid species, measured in 7174 Finnish individuals, by utilising either 11 high-impact genomic loci or genome-wide polygenic scores (PGS). We assessed the impact of the lipid species on seven diseases by performing disease association across FinnGen (n = 500,348), UK Biobank (n = 420,531), and Generation Scotland (n = 20,032). We performed univariable Mendelian randomisation (MR) and multivariable MR (MVMR) analyses to examine whether lipid species impact disease risk independently of standard lipids.

FINDINGS

PGS explained >4% of the variance for 34 lipid species but variants outside the high-impact loci had only a marginal contribution. Variants within the high-impact loci showed association with all seven diseases. MVMR supported a causal role of ApoB in ischaemic heart disease after accounting for lipid species. Phosphatidylethanolamine-increasing LIPC variants seemed to lower age-related macular degeneration risk independently of HDL-cholesterol. MVMR suggested a protective effect of four lipid species containing arachidonic acid on cholelithiasis risk independently of Total Cholesterol.

INTERPRETATION

Our study demonstrates how genetic predictors of lipid species can be utilised to gain insights into disease risk. We report potential links between lipid species and age-related macular degeneration and cholelithiasis risk, which can be explored for their utility in disease risk prediction and therapy.

FUNDING

The funders had no role in the study design, data analyses, interpretation, or writing of this article.

A fasting-mimicking diet programme reduces liver fat and liver inflammation/fibrosis measured by magnetic resonance imaging in patients with type 2 diabetes

BACKGROUND & AIMS

This study aimed to assess whether a fasting-mimicking diet (FMD) programme as an adjunct to usual care can reduce liver fat and liver inflammation/fibrosis as measured by Magnetic Resonance Imaging (MRI) in patients with type 2 diabetes.

METHODS

This study analyses secondary outcomes of the Fasting In diabetes Treatment (FIT) trial, which was a randomised, controlled, assessor-blinded trial in which people with type 2 diabetes using metformin only and/or diet alone for glycaemic control were randomised to receive 5-consecutive day cycles of FMD monthly as adjunct to usual care or usual care only for twelve months. Laboratory measurements, anthropometric measurements and MRI were performed at baseline, 6 and 12 months. Two MRI-derived biomarkers were measured: proton density fat-fraction (PDFF), a biomarker for liver fat, and iron content corrected T1 (cT1), a biomarker for liver inflammation/fibrosis.

RESULTS

Data were available of 89 participants who completed baseline visits including MRI (n = 48 in the FMD group and n = 41 in the control group). Intention-to-treat analyses, using linear mixed models, revealed significant adjusted estimated treatment effects of the FMD on PDFF (-2.8 %, 95 % CI -4.7 to -0.8, p < 0.01) and cT1 (-29.9 ms, 95 % CI -51.8 to -8.0, p < 0.01) at 12 months. In a post-hoc analysis, more participants in the FMD group compared to the control group transitioned from high to low risk for liver disease and cardiovascular disease based on PDFF ≥5.6 %. In the FMD and control group combined, every percent decrease in PDFF was associated with a decrease in HbA1c of 0.75 mmol/mol (95 % CI 0.51 to 0.99), fasting glucose of 0.14 mmol/L (95 % CI 0.08 to 0.20), triglycerides of 0.04 mmol/L (95 % CI 0.02 to 0.07), total cholesterol of 0.03 mmol/L (95 % CI 0.01 to 0.05) and weight of 0.52 kg (CI 0.33 to 0.70). Every millisecond decrease in cT1 was associated with a decrease in HbA1c of 0.05 mmol/mol (95 % CI 0.02 to 0.08), fasting glucose of 0.01 mmol/L (95 % CI 0.00 to 0.02) and weight of 0.04 kg (CI 0.01 to 0.06).

CONCLUSION

Following an FMD programme for 5-consecutive days per month for twelve months reduces both liver PDFF and cT1 MRI-derived biomarkers in patients with type 2 diabetes, indicating a reduction in liver fat and liver inflammation/fibrosis. Decreases in PDFF and cT1 are associated with decreases in HbA1c, fasting glucose, triglycerides and weight. Decrease in PDFF was also associated with a decrease in total cholesterol. Monthly cycles of an FMD appear to be a valuable adjunct to regular treatment of type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03811587.

Research progress on the regulatory role of different cell death pathways in metabolic-dysfunction-associated steatotic liver disease

Metabolic dysfunction associated steatotic liver disease (MASLD) is one of the most common chronic liver diseases that pose a significant threat to human health. An essential process in developing various diseases, including MASLD, is programmed cell death, a regulated and controlled mechanism that eliminates damaged or unnecessary cells. It is a ubiquitous process during organismal development and represents an active, orderly form of cell death. Significant progress has been made in studying programmed cell death in the context of MASLD. This review systematically summarizes various forms of cell death, including apoptosis, Pyroptosis, autophagy, ferroptosis, and cuproptosis, along with their regulatory mechanisms in MASLD. It has been observed that there are interactions between different forms of cell death. As MASLD progresses through inflammation, fibrosis, and cirrhosis stages, multiple forms of cell death may act synergistically. This article aims to provide the latest research findings and theoretical insights to further our understanding of the pathogenesis of MASLD.

Performance of Magnetic Resonance Imaging and Ultrasound for Identifying the Different Degrees of Hepatic Steatosis: A Systematic Review and Meta-analysis

BACKGROUND

MRI proton density fat fraction (MRI-PDFF), controlled attenuation parameters (CAP), and attenuation coefficients (AC) are capable of steatosis characterization and may be useful as noninvasive alternatives for diagnosing hepatic steatosis.

PURPOSE

This meta-analysis aimed to evaluate the performance of MRI-PDFF, CAP, and AC in grading hepatic steatosis, using histology as the reference standard.

METHODS

We conducted a comprehensive search of the PubMed, Cochrane Library, Embase, and Web of Science databases until June 2024. The quality of eligible studies was assessed. Pooled sensitivity, specificity, and area under receiver operating characteristic (AUC) curves were calculated using a bivariate random-effects model. Meta-regression analysis, subgroup analysis, and Deeks' test were performed to explore heterogeneity and assess publication bias.

RESULTS

This meta-analysis included 38 studies with 5056 patients with metabolic dysfunction-associated steatotic liver disease. The AUC values for grading steatosis ≥S1, ≥S2, and ≥S3 were 0.99, 0.89, and 0.90 for MRI-PDFF, 0.95, 0.84, and 0.77 for CAP, and 0.97, 0.90, and 0.89 for AC, respectively. CAP demonstrated lower accuracy for detecting steatosis grades ≥S2 and ≥S3 compared to MRI-PDFF (0.89 vs. 0.84, p<0.001; 0.90 vs. 0.77, p<0.001) and AC (0.90 vs. 0.84, p<0.001; 0.89 vs. 0.77, p<0.001). Subgroup analyses revealed that MRI-PDFF and CAP exhibited superior diagnostic performance in diagnosing ≥S2 and ≥S3 steatosis among individuals in Asia, with a body mass index ≤30 kg/m2, and age <51 years.

CONCLUSION

A direct comparison with CAP showed greater accuracy for MRI-PDFF and AC in diagnosing moderate and severe steatosis, and similar diagnostic performance for MRI-PDFF and AC. For patients with steatosis, AC should be incorporated into routine ultrasound screening.

Molecular Landscape and Diagnostic Model of MASH: Transcriptomic, Proteomic, Metabolomic, and Lipidomic Perspectives

Metabolic dysfunction-associated steatohepatitis (MASH), a progressive form of fatty liver disease, presents a significant global health challenge. Despite extensive research, fully elucidating its complex pathogenesis and developing accurate non-invasive diagnostic tools remain key goals. Multi-omics approaches, integrating data from transcriptomics, proteomics, metabolomics, and lipidomics, offer a powerful strategy to achieve these aims. This review summarizes key findings from multi-omics studies in MASH, highlighting their contributions to our understanding of disease mechanisms and the development of improved diagnostic models. Transcriptomic studies have revealed widespread gene dysregulation affecting lipid metabolism, inflammation, and fibrosis, while proteomics has identified altered protein expression patterns and potential biomarkers. Metabolomic and lipidomic analyses have further uncovered significant changes in various metabolites and lipid species, including ceramides, sphingomyelins, phospholipids, and bile acids, underscoring the central role of lipid dysregulation in MASH. These multi-omics findings have been leveraged to develop novel diagnostic models, some incorporating machine learning algorithms, with improved accuracy compared to traditional methods. Further research is needed to validate these findings, explore the complex interplay between different omics layers, and translate these discoveries into clinically useful tools for improved MASH diagnosis and prognosis.

Cardiac Remodeling and Arrhythmic Burden in Pre-Transplant Cirrhotic Patients: Pathophysiological Mechanisms and Management Strategies

Background: Chronic liver disease (CLD) and cirrhosis contribute to approximately 2 million deaths annually, with primary causes including alcohol-related liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and chronic hepatitis B and C infections. Among these, MASLD has emerged as a significant global health concern, closely linked to metabolic disorders and a leading cause of liver failure and transplantation. Objective: This review aims to highlight the interplay between cirrhosis and cardiac dysfunction, emphasizing the pathophysiology, diagnostic criteria, and management of cirrhotic cardiomyopathy (CCM). Methods: A comprehensive literature review was conducted to evaluate the hemodynamic and structural cardiac alterations in cirrhosis. Results: Cirrhosis leads to portal hypertension and systemic inflammation, contributing to CCM, which manifests as subclinical cardiac dysfunction, impaired contractility, and electrophysiological abnormalities. Structural changes, such as increased left ventricular mass, myocardial fibrosis, and ion channel dysfunction, further impair cardiac function. Vasodilation in the splanchnic circulation reduces peripheral resistance, triggering compensatory tachycardia, while the activation of the renin-angiotensin-aldosterone system (RAAS) promotes fluid retention and increases cardiac preload. Chronic inflammation and endotoxemia exacerbate myocardial dysfunction. The 2005 World Congress of Gastroenterology (WCG) and the 2019 Cirrhotic Cardiomyopathy Consortium (CCC) criteria provide updated diagnostic frameworks that incorporate global longitudinal strain (GLS) and tissue Doppler imaging (TDI). Prolonged QT intervals and arrhythmias are frequently observed. Managing heart failure in cirrhotic patients remains complex due to intolerance to afterload-reducing agents, and beta-blockers require careful use due to potential systemic hypotension. The interaction between CCM and major interventions, such as transjugular intrahepatic portosystemic shunt (TIPS) and orthotopic liver transplantation (OLT), highlights the critical need for thorough preoperative cardiac evaluation and vigilant postoperative monitoring. Conclusions: CCM is a frequently underdiagnosed yet significant complication of cirrhosis, impacting prognosis, particularly post-liver transplantation. Early identification using echocardiography and thorough evaluations of arrhythmia risk in cirrhotic patients are critical for optimizing management strategies. Future research should focus on targeted therapeutic approaches to mitigate the cardiac burden in cirrhotic patients and improve clinical outcomes.

Construction and evaluation of a diagnostic model for metabolic dysfunction-associated steatotic liver disease based on advanced glycation end products and their receptors

Background

Effective biomarkers for the diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD) remain limited. This study aims to evaluate the potential of advanced glycation end products (AGEs) and their endogenous secretory receptor (esRAGE) as non-invasive biomarkers for diagnosing MASLD, to explore differences between obese and non-obese MASLD patients, and to develop a novel diagnostic model based on these biomarkers.

Methods

This study enrolled 341 participants, including 246 MASLD patients (118 non-obese, 128 obese) and 95 healthy controls. Serum AGEs and esRAGE levels were measured by ELISA. Key predictors were identified using the Lasso algorithm, and a diagnostic model was developed with logistic regression and visualized as nomograms. Diagnostic accuracy and utility were evaluated through the area under the curve (AUC), bootstrap validation, calibration curves, and decision curve analysis (DCA).

Results

Serum AGEs and esRAGE levels were significantly higher in MASLD patients compared to controls. Moreover, obese MASLD patients had higher esRAGE levels than non-obese ones, but no significant difference in AGEs levels was found. A diagnostic model incorporating age, WC, BMI, ALT, TG, HDL, AGEs, and esRAGE achieved an AUC of 0.963, with 94.3% sensitivity and 85.3% specificity. The AUC for bootstrap internal validation was 0.963 (95% CI: 0.944-0.982). Calibration curves showed strong predictive accuracy, and DCA demonstrated high net clinical benefit.

Conclusion

Serum AGEs and esRAGE serve as non-invasive biomarkers for distinguishing MASLD patients. We developed and validated diagnostic models for MASLD, offering valuable tools to identify at-risk populations and improve prevention and treatment strategies.

Endocrinology and Metabolic Diseases in Human Health

In 2022, we served as guest editors of the Nutrients Special Issue entitled "Endocrinology and Metabolic Diseases in Human Health". [...].

Metabolic dysfunction-associated fatty liver disease and risks of incident coronary artery disease and cerebrovascular disease: LIFE Study

AIM

To estimate the risks of coronary artery and cerebrovascular diseases in metabolic dysfunction-associated fatty liver disease (MAFLD) using different fatty liver index (FLI) cut-off values in a Japanese population.

METHODS

We analyzed insurance claims and health checkup data from public medical insurance enrollees aged ≥40 years in seven Japanese municipalities who had undergone a health checkup between April 2015 and March 2022. The MAFLD cases were identified as hepatic steatosis (defined as FLI ≥60 or ≥37) with overweight/obesity, diabetes, or lean/normal weight with metabolic dysregulation. Cox proportional hazards models estimated adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for MAFLD (reference: non-MAFLD) regarding incident coronary artery and cerebrovascular diseases. Covariates included age, sex, smoking habit, low-density lipoprotein cholesterol level, and statin use.

RESULTS

The study was undertaken using 163 834 individuals. The HRs of MAFLD for coronary artery disease were 1.44 (95% CI, 1.24-1.67) for FLI ≥ 60 and 1.49 (95% CI, 1.32-1.68) for FLI ≥ 37. The HRs of MAFLD for cerebrovascular disease were 1.58 (95% CI, 1.22-2.05) for FLI ≥ 60 and 1.41 (95% CI, 1.15-1.74) for FLI ≥ 37. In women, neither FLI cut-off was associated with coronary artery disease, and only FLI ≥ 60 was associated with cerebrovascular disease.

CONCLUSIONS

The MAFLD cases identified using the two FLI cut-off values were at higher risk for coronary artery and cerebrovascular diseases. Asian-specific FLI cut-offs may better identify hepatic steatosis in Japan than Western-specific cut-offs, but there is a need to consider sex differences when determining at-risk subgroups for targeted health interventions.

Early stage of metabolic dysfunction associated steatotic liver disease disrupts circadian rhythm and induces neuroinflammation in rats

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is a chronic liver disease affecting 25% of the European population, with rising global incidence. Liver damage includes ballooning, steatosis, inflammation and fibrosis. Associated brain disorders include sleep, cognitive issues, anxiety, and depression. While neurological complications in advanced MASLD are well documented, early cerebral manifestations remain largely unexplored. This study aimed at developing an MASLD rat model to assess the onset of early brain damage, focusing on impairments of the circadian cycle rhythm and associated neuroinflammation. Sprague Dawley rats were divided into two groups: one received a high-fat, high-cholesterol (HFHC) diet for 90 days, while the other received a standard diet. Histological analysis showed significant hepatic steatosis, ballooning, and inflammation in the HFHC group (p < 0.01). These lesions correlated with elevated hepatic triglycerides (p < 0.01), increased Alanine Aminotransferase, Aspartate Aminotransferase, total cholesterol, and low-density lipoprotein, alongside decreased plasma high-density lipoprotein. Behavioural analysis using activity wheels revealed that the HFHC rats steadily maintained their activity level during the rest periods when compared with controls (p < 0.05). This behavioural alteration occurred alongside neuroinflammation, demonstrated by changes in the expression of 36 and 17 inflammatory mediators in the cerebellum and frontal cortex respectively. These changes were associated with an increase in the expression of glial cell markers (Aif1 and Gfap genes) and an increase in the number of microglial cells, affecting the frontal cortex and cerebellum differently. This rat model of early MASLD shows circadian rhythm disturbances, which could reflect sleep disorders in humans. These early brain disturbances specific to MASLD, which occur before the symptoms of liver disease become clinically apparent, could therefore be used as an early diagnosis marker for MASLD patients.

Metabolic dysfunction-associated steatotic liver disease (MASLD): Exploring systemic impacts and innovative therapies

Metabolic dysfunction-associated steatotic liver disease (MASLD), which includes the inflammatory subtype metabolic dysfunction-associated steatohepatitis, is a prominent cause of chronic liver disease with systemic effects. Insulin resistance, obesity, and dyslipidaemia produce MASLD in over 30 % of adults. It is a global health issue. From MASLD to MASH, hepatic inflammation and fibrosis grow, leading to cirrhosis, hepatocellular cancer, and extrahepatic complications such CVD, CKD, and sarcopenia. Effects of MASLD to MASH are mediated through mechanisms that include inflammation, oxidative stress, dysbiosis, and predisposition through genetic makeup. Advances in diagnostic nomenclature in the past few years have moved the emphasis away from NAFLD to MASLD, focusing on the metabolic etiology and away from the stigma of an alcoholic-related condition. Epidemiological data show a large geographical variability and increasing prevalence in younger populations, particularly in regions with high carbohydrate-rich diets and central adiposity. Lifestyle modification is considered as the main management of MASLD currently. This may include dietary intervention, exercise, and weight loss management. Pharmaceutical management is primarily aimed at metabolic dysfunction with promising findings for GLP-1 receptor agonists, pioglitazone and SGLT-2 inhibitors, which can correct both hepatic and systemic outcome. However, it still depends on well-integrated multidisciplinary care models by considering complex relationships between MASLD and its effects on extrahepatic organs. Determining complications at an early stage; developing precision medicine strategies; exploring new therapeutic targets will represent crucial factors in improving their outcomes. This review discuss the systemic nature of MASLD and calls for multiple collaborations to reduce its far-reaching health impacts and our quest for understanding its pathological mechanisms. Thus, collective efforts that are required to address MASLD are under the public health, clinical care, and research angles toward effectively containing its rapidly increasing burden.

Electroacupuncture Attenuates Intestinal Barrier Disruption via the α7nAChR-Mediated HO-1/p38 MAPK/NF-κB Pathway in a Mouse Model of Metabolic Dysfunction-Associated Fatty Liver Disease: A Randomized, Single-Blind, Controlled Trial

Background: Gut barrier integrity plays a crucial role in the pathogenesis of metabolic dysfunction-associated fatty liver disease (MAFLD). Electroacupuncture (EA) at ST-36 can ameliorate inflammatory responses via stimulating the α7 nicotinic acetylcholine receptor (α7nAChR), but whether EA is effective in preserving the intestinal barrier of MAFLD has not been exactly illustrated. This investigation explored potential protection mechanisms of EA at ST-36 targeting the dismantled gut barrier in MAFLD. Methods: C57BL/6 mice were randomly allocated into several subgroups: control (CON), high-fat diet (HFD), HFD with EA, HFD with EA and α7nAChR inhibitor α-BGT, and HFD with EA and intestinal HO-1 knockout (KO). Body weight, liver weight, visceral fat index, and histopathological examination of the liver and the intestine were determined. Serum biological indexes were evaluated through corresponding kits. Furthermore, the expressions of HO-1, α7nAChR, gut barrier-associated proteins, and the molecular mechanisms in intestinal tissues were assessed via Western blot, RT-qPCR, immunohistology, or immunofluorescence examination. Results: EA treatment decreased body weight, liver weight, and visceral fat index gain and mitigated liver function injury and abnormal lipid indexes, exhibiting less severity of hepatic steatosis, fibrosis, and inflammation responses of MAFLD. Lower gut permeability, less intestinal epithelial disruption, and upregulation of tight junction proteins after EA suggested the protective effects in attenuating intestinal epithelial barrier dysfunction. These protective effects were abolished by α-BGT or intestinal HO-1 deletion. Mechanistically, EA markedly enriched α7nAChR and HO-1 expression and mitigated phosphorylated p38 MAPK/NF-κB activation, which was lost in α-BGT or HO-1 KO treatment. Conclusions: The protective effects of EA at ST-36 in the pathogenesis of MAFLD may be attributed to the preserved intestinal barrier, thereby alleviating systemic inflammatory responses and preventing subsequent liver hits, where the α7nAChR-mediated HO-1/p38 MAPK/NF-κB pathway was crucial to maintain homeostasis.

Association of cardiovascular health metrics and metabolic associated fatty liver disease: Methodological limitations, and future directions

Metabolic-associated fatty liver disease (MAFLD), formerly known as nonalcoholic fatty liver disease, is an increasing global health challenge with substantial implications for metabolic and cardiovascular health (CVH). A recent study by Fu et al investigated the relationship between CVH metrics, specifically Life's Simple 7 and Life's Essential 8, and the prevalence of MAFLD. While this study offered important insights into the relationship between CVH and MAFLD, several methodological limitations, unaddressed confounding factors, and potential biases that could impact the interpretation of their findings should be considered. The study's cross-sectional nature restricted the ability to draw causal conclusions, and it did not fully account for potential confounding factors such as dietary habits, genetic predispositions, and medication use. Furthermore, relying on transient elastography to diagnose MAFLD introduces certain diagnostic limitations. Longitudinal study designs, advanced statistical modeling techniques, and diverse population groups should be utilized to strengthen future research. Exploring the mechanistic pathways that link CVH metrics to MAFLD through multi-omics approaches and interventional studies will be essential in formulating targeted prevention and treatment strategies. Structural equation modeling and machine learning techniques could provide a more refined analysis of these interrelated factors. Additionally, future research should employ longitudinal study designs and explore genetic and epigenetic influences to enhance our understanding of CVH and MAFLD interactions.

Association of platelet to albumin ratio with metabolic dysfunction-associated steatotic liver disease based on the National Health and Nutrition Survey 2017-2018

The prevalence and incidence of metabolic dysfunction-associated steatotic liver disease (MASLD) are significantly increasing globally, but the index of non-invasive disease is limited. Platelet-albumin ratio(PAR) is a non-invasive biomarker of inflammation, the aim of this study was to evaluate the relationship between PAR and MASLD. This population-based cross-sectional retrospective study analyzed data extracted from the National Health and Nutrition Survey (NHANES) database from 2017 to 2018. Multivariate logistic regression analysis was used to evaluate the correlation between PAR and MASLD in different models. Model I was unadjusted, model II adjusted for race, sex and age, and model III was adjusted based on model II plus smoking status, hypertension, and diabetes. Further subgroup analysis was carried out according to sex, age, hypertension and diabetes status. The study involved 3287 participants, of whom 873 (26.5%) were diagnosed with MASLD. The PAR level in MASLD group was significantly higher than non-MASLD group (P < 0.05). Multivariate logistic regression revealed that high PAR level was an independent risk factor for MASLD (OR = 2.58, 95%CI: 1.26-5.27, P = 0.03), which adjusted for sex, age, race, smoking status, hypertension, and diabetes.The same results were observed in multiple subgroups of further subgroup analysis, and it can effectively predict the risk of MASLD (AUC = 0.842, 95% CI: 0.826-0.859). In conclusion, the new biomarker PAR shows a positive correlation with the risk of MASLD in the population, and can be used as a biomarker of MASLD to help clinicians identify people at high risk of MASLD.

Body mass index and diabetes predict severity of liver fibrosis across the spectrum of steatotic liver disease

INTRODUCTION AND OBJECTIVES

Recent evidence indicates that metabolic dysfunction and alcohol-associated steatotic liver disease (MetALD), a newly defined subgroup of steatotic liver disease (SLD), may have a worse prognosis than metabolic dysfunction-associated steatotic liver disease (MASLD). This study examines the clinical factors influencing the severity of MetALD to inform and improve future management strategies.

PATIENTS AND METHODS

Data from the 2017-2020 National Health and Nutrition Examination Surveys (NHANES), involving 7745 adults with valid elastography measurements, were utilized to define and estimate the prevalence of MASLD, MetALD, and alcohol liver disease (ALD). Controlled attenuation parameter (CAP) ≥285 dB/m, liver stiffness measurement (LSM) ≥8 kPa, and ≥12 kPa indicated the presence of hepatic steatosis, clinically significant fibrosis, and advanced fibrosis, respectively.

RESULTS

The prevalence of MetALD was 4 % (N=287), compared to 24 % (N=2049) for MASLD and 7 % (N=486) for ALD. The prevalence of significant fibrosis and advanced fibrosis in MetALD was 10.8 % and 3.1 %, respectively, compared to 24.7 % and 9.8 % in MASLD, and 15 % and 8 % in ALD. Logistic regression analysis among MetALD patients showed that higher body mass index (BMI) (odds ratio [OR]: 1.15, 95 % CI: 1.08-1.23, P<0.01) and diabetes mellitus (DM) (OR: 3.0, 95 % CI: 1.06-6.2, P<0.01) were associated with an increased risk of fibrosis. These factors were also identified as independent risk factors for fibrosis in patients with MASLD and ALD.

CONCLUSIONS

MetALD had the lowest prevalence and fibrosis severity among the three groups of SLD. Elevated BMI and DM were associated with the severity of liver disease, and these findings provide a rationale for the use of obesity- and diabetes-targeted medications in these individuals.

Relationship between anthropometric measures and the risk of incident Metabolic dysfunction-associated steatotic liver disease: a longitudinal study

BACKGROUND

Waist circumference (WC) and body mass index (BMI) are considered useful for the diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD). This study aimed to investigate the association between the body roundness index (BRI) and a body shape index (ABSI) with incident MASLD, in comparison to WC and BMI.

METHODS

Retrospective cohort data from a Japanese health check-up program were analyzed. Logistic regression model was used to evaluate the associations between anthropometric measure quartiles and MASLD, and receiver operating characteristic (ROC) analysis was performed to evaluate the associations between anthropometric measures and incident MASLD, stratified by sex.

RESULTS

A total of 10,561 males and 7,187 females were included, of whom 3,182 males and 914 females developed MASLD. Multivariate analysis revealed that higher WC, BMI, and BRI were associated with incident MASLD in both sexes, whereas higher ABSI was significantly associated with incident MASLD only in females. Among males, the area under the ROC curve (AUC) of BMI was higher than that of WC, BRI, and ABSI. Conversely, among females, the AUC of BMI was higher than that of ABSI, whereas it was comparable to that of WC or BRI. The AUC and the optimal cut-off values of BMI for predicting incident MASLD were 0.77 and 23.9 kg/m2 in males, and 0.86 and 22.2 kg/m2 in females. The optimal cut-off values of WC were 82.0 cm for males and 76.3 cm for females, respectively.

CONCLUSIONS

We demonstrated the strongest association between BMI and incident MASLD compared to other measures, particularly in males, while also showing a strong association in females. Additionally, specific WC criteria for Asians to improve MASLD diagnosis are needed.

Diagnosis and Management of Early Stages of ALD

Early forms of alcohol-associated liver disease (ALD) include different stages in the progression of compensated liver disease ranging from steatosis to steatohepatitis and fibrosis. ALD has been classically diagnosed at advanced stages more frequently than other liver diseases. This fact probably contributed to the scarcity of studies on early forms of ALD. Recent studies have investigated the prevalence of early ALD in the general population and have described the natural history of alcohol-induced steatosis and fibrosis, which have been linked to worse prognosis compared with early stages of other chronic liver diseases. In addition, studies on screening and early diagnosis of ALD in at-risk populations have shown that these strategies allow early detection and intervention. Of note, up to 28% of the United States population has concurrent alcohol use and metabolic syndrome, and estimated prevalence of advanced fibrosis among heavy drinkers with metabolic syndrome has increased from 3% in the 1990s to more than 10% in the 2010s. Therefore, new challenges and treatment opportunities will emerge for patients with ALD. In this review, we provide an overview of the state of the art in early ALD, focusing on natural history, diagnosis, and management, and provide insights into future perspectives.

Effect of luseogliflozin on liver fibrosis differs depending on alcohol consumption in patients with type 2 diabetes

AIM

Changes in FIB-4 levels after the initiation of luseogliflozin therapy were compared between patients with type 2 diabetes according to the presence or absence of alcohol consumption.

METHODS

A total of 192 patients with type 2 diabetes who continued luseogliflozin therapy for over 12 months were retrospectively investigated. The primary outcome was the change in FIB-4. The secondary outcomes were changes in HbA1c, body weight, and serum albumin concentration. A current drinker was defined as an individual consuming >20 g ethanol equivalent/day. Patients were classified according to their risk of developing liver fibrosis into the low-risk (FIB-4 < 1.3) and intermediate/high-risk (FIB-4 ≥ 1.3) groups.

RESULTS

In the low-risk group, while FIB-4 increased dramatically from 0.91 ± 0.30 at the baseline to 1.14 ± 0.34 at 12 months in drinkers (n = 27), non-drinkers (n = 79) showed no significant change (0.87 ± 0.22-0.91 ± 0.26). In the intermediate/high-risk group (n = 63), although the FIB-4 in drinkers (n = 23) showed no significant change (2.18 ± 1.00-2.16 ± 0.93), it significantly decreased from 2.10 ± 0.87 to 1.80 ± 0.68 in non-drinkers (n = 63). In both the low- and intermediate/high-risk groups, HbA1c and body weight significantly decreased in both drinkers and non-drinkers. Serum albumin concentrations significantly increased in both drinkers and non-drinkers in the low-risk group. Although serum albumin concentration did not significantly change in drinkers, it dramatically increased in non-drinkers in the intermediate/high-risk group.

CONCLUSIONS

HbA1c levels and body weight decreased in patients with type 2 diabetes after initiating luseogliflozin therapy, regardless of drinking habits. However, it is desirable to limit alcohol consumption when considering its effects on liver fibrosis.

The Role of the Gut-Biliary-Liver Axis in Primary Hepatobiliary Liver Cancers: From Molecular Insights to Clinical Applications

Background: Hepatobiliary liver cancers (HBLCs) represent the sixth most common neoplasm in the world. Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) constitute the main HBLC types, with alarming epidemiological projections. Methods: In recent decades, alterations in gut microbiota, with mutual implications on the gut-liver axis and gut-biliary axis permeability status, have been massively investigated and proposed as HBLC pathogenetic deus ex machina. Results: In the HCC setting, elevated intestinal levels of Escherichia coli and other Gram-negative bacteria have been demonstrated, resulting in a close association with increased lipopolysaccharide (LPS) serum levels and, consequently, chronic systemic inflammation. In contrast, the intestinal microbiota of HCC individuals feature reduced levels of Lactobacillus spp., Bifidobacterium spp., and Enterococcus spp. In the CC setting, evidence has revealed an increased expression of Lactobacillus spp., with enhanced levels of Actynomices spp. and Alloscardovia spp. Besides impaired strains/species representation, gut-derived metabolites, including bile acids (BAs), short-chain fatty acids (SCFAs), and oxidative-stress-derived products, configure a network severely impacting the progression of HBLC. Conclusions: In the era of Precision Medicine, the clarification of microbiota composition and functioning in HCC and CC settings can contribute to the identification of individual signatures, potentially providing novel diagnostic markers, therapeutic approaches, and prognostic/predictive tools.

Validation of the diagnostic accuracy of the acFibroMASH index for at-risk MASH in patients with metabolic dysfunction-associated steatotic liver disease

OBJECTIVE

The objective of this study was to validate the diagnostic accuracy of the acFibroMASH index in a population of metabolic dysfunction-associated steatotic liver disease (MASLD) patients with at-risk metabolic dysfunction-associated steatohepatitis (MASH) and to compare it with other scoring systems.

METHODS

394 patients with biopsy-proven MASLD were retrospectively enrolled. The patients were divided into the at-risk MASH (NAFLD activity score ≥ 4 and significant fibrosis) group (n = 103) and the non-at-risk MASH group (n = 291). The diagnostic performance of the acFibroMASH index was compared to that of fibroScan-aspartate aminotransferase (FAST) and other noninvasive fibrosis scores by plotting the receiver operating characteristic curve (ROC), including the area under the curve (AUC), sensitivity, and specificity. Cut-offs of the acFibroMASH index for sensitivity (≥ 0.90) and specificity (≥ 0.90) were obtained in our cohort.

RESULTS

The AUC of the acFibroMASH index in assessing at-risk MASH was 0.780, while the AUC of FAST was 0.770. The comparison of acFibroMASH with FAST showed no significant difference (P = 0.542). When the cut-off value for acFibroMASH was < 0.15, 95.5% of at-risk MASH patients could be excluded in 89 patients correctly. Conversely, when the cut-off value was set at > 0.39, 49.3% of at-risk MASH patients could be diagnosed in 140 patients correctly. When the NPV was set at 0.900, the critical value for exclusion was determined to be 0.23, with a sensitivity of 0.835 and a specificity of 0.526.

CONCLUSION

This study validated the efficacy of the acFibroMASH index in predicting at-risk MASH in a population of MASLD patients, demonstrating comparable performance to that of the FAST. The acFibroMASH index may provide a valuable clinical basis for screening and identifying at-risk MASH in primary care settings.

Attenuation imaging: Diagnostic differences in hepatic steatosis for chronic hepatitis B vs metabolic dysfunction-associated steatotic liver disease patients

BACKGROUND

Hepatic steatosis, characterized by fat accumulation in hepatocytes, can result from metabolic dysfunction-associated steatotic liver disease (MASLD), infections, alcoholism, chemotherapy, and toxins. MASLD is diagnosed via imaging or biopsy with metabolic criteria and may progress to metabolic dysfunction-associated steatohepatitis, potentially leading to fibrosis, cirrhosis, or cancer. The coexistence of hepatic steatosis with chronic hepatitis B (CHB) is mainly related to metabolic factors and increases mortality and cancer risks. As a noninvasive method, attenuation imaging (ATI) shows promise in quantifying liver fat, demonstrating strong correlation with liver biopsy.

AIM

To investigate the disparity of ATI for assessing biopsy-based hepatic steatosis in CHB patients and MASLD patients.

METHODS

The study enrolled 249 patients who underwent both ATI and liver biopsy, including 78 with CHB and 171 with MASLD. Hepatic steatosis was classified into grades S0 to S3 according to the proportion of fat cells present. Liver fibrosis was staged from 0 to 4 according to the meta-analysis of histological data in viral hepatitis scoring system. The diagnostic performance of attenuation coefficient (AC) values across different groups was compared for each grade of steatosis. Factors associated with the AC values were determined through linear regression analysis. A multivariate logistic regression model was established to predict ≥ S2 within the MASLD group.

RESULTS

In both the CHB and the MASLD groups, AC values increased significantly with higher steatosis grade (P < 0.001). In the CHB group, the areas under the curve (AUCs) of AC for predicting steatosis grades ≥ S1, ≥ S2 and S3 were 0.918, 0.960 and 0.987, respectively. In contrast, the MASLD group showed AUCs of 0.836, 0.774, and 0.688 for the same steatosis grades. The diagnostic performance of AC for detecting ≥ S2 and S3 indicated significant differences between the two groups (both P < 0.001). Multivariate linear regression analysis identified body mass index, triglycerides, and steatosis grade as significant factors for AC. When the steatosis grade is ≥ S2, it can progress to more serious liver conditions. A clinical model integrating blood biochemical parameters and AC was developed in the MASLD group to enhance the prediction of ≥ S2, achieving an AUC of 0.848.

CONCLUSION

The AC could effectively discriminate the degree of steatosis in both the CHB and MASLD groups. In the MASLD group, when combined with blood biochemical parameters, AC exhibited better predictive ability for moderate to severe steatosis.

Mechanisms of rifaximin inhibition of hepatic fibrosis in mice with metabolic dysfunction associated steatohepatitis through the TLR4/NFκB pathway

Metabolic dysfunction-associated steatohepatitis (MASH) has become a serious public health problem, posing an increasingly dangerous threat to human health owing to its increasing prevalence and accompanying intra- and extrahepatic adverse outcomes. Rifaximin is considered to have therapeutic potential for MASH; however, its efficacy remains controversial. Our study aimed to observe the ameliorative effects of rifaximin and explore its possible mechanisms at the cellular level. 1. 42 male C57BL/6J mice were divided into 3 groups, the CON group and MCD group were fed with normal feed and MCD feed for 12 weeks respectively, and the MCD + RFX group was treated with rifaximin by gavage for 4 weeks on the basis of MCD feed. Hematoxylin-eosin staining, Sirius red staining and immunohistochemical staining were used to observe the histopathological changes of liver and intestine. Differences in liver transaminases, inflammatory factors, fibrosis indexes and intestinal tight junction proteins were compared among the 3 groups of mice. 2. A MASH cell model was constructed by inducing HepG2 cells with free fatty acids to observe the effects of rifaximin on MASH in vitro. In addition, the effects of rifaximin on TLR4/NF-κB signaling pathway were explored by applying TLR4 agonist LPS and TLR4 inhibitor TAK-242. Hepatic histopathology was significantly improved in MASH mice after rifaximin treatment, and their serum alanine aminotransferase and aspartate aminotransferase levels were (72.72 ± 5.68) U/L and (222.8 ± 11.22) U/L, respectively, which were significantly lower than those in the MCD group [(293.3 ± 10.69) U/L and (414.1 ± 36.29) U/L, P < 0.05], and the levels of inflammatory factors and fibrosis indicators were reduced. Rifaximin ameliorated intestinal barrier injury with increased expression of intestinal tight junction protein ZO-1 in the MCD + RFX group of mice, and the concentration of LPS-binding proteins (4.92 ± 0.55 vs. 15.82 ± 1.71, P < 0.05) was lower than that in the MCD group. In the NASH cell model, rifaximin similarly exerted inhibitory effects on its inflammatory factors and TLR4/NF-κB signaling pathway. Application of TLR4 inhibitors weakened the inhibitory effect of rifaximin on MASH. Our study supports rifaximin as a potential treatment for MASH, with potential mechanisms related to improving intestinal barrier integrity and downregulating the TLR4/NF-κB signaling pathway.

Development and validation of a scoring system to predict MASLD patients with significant hepatic fibrosis

To address the need for a simple model to predict ≥ F2 fibrosis in metabolic dysfunction-associated steatotic liver disease (MASLD) patients, a study utilized data from 791 biopsy-proven MASLD patients from the NASH Clinical Research Network and Jinan University First Affiliated Hospital. The data were divided into training and internal testing sets through randomized stratified sampling. A multivariable logistic regression model using key categorical variables was developed to identify ≥ F2 fibrosis. External validation was performed using data from the FLINT trial and multiple centers in China. The DA-GAG score, incorporating diabetes, age, GGT, aspartate aminotransferase/ platelet ratio, and globulin/ total protein ratio, demonstrated superior performance in distinguishing ≥ F2 fibrosis with an area under the receiver operating characteristic curve of 0.79 in training and over 0.80 in testing datasets. The DA-GAG score efficiently identifies MASLD patients with ≥ F2 fibrosis, significantly reducing the medical burden.

Gout drives metabolic dysfunction-associated steatotic liver disease through gut microbiota and inflammatory mediators

This study explores the relationship between gout and metabolic dysfunction-associated steatotic liver disease (MASLD), two metabolic conditions linked to worsening health outcomes. While hyperuricemia's association with MASLD is established, the specific connection between gout and MASLD remains less explored. Using data from the UK Biobank, the study employs COX proportional hazard models, multi-state survival analysis, and Mendelian randomization to assess the independent and mutual risks of gout and MASLD. Findings indicate a mutual risk increase: male gout patients, those younger than 60, and those with high BMI are particularly susceptible to MASLD, while female MASLD patients are at heightened risk for gout. Shared risk factors for both conditions include high BMI, hypertension, diabetes, and hyperuricemia. The study further identifies a bidirectional causal link, with gout leading to MASLD, mediated by gut microbiota Ruminococcaceae and proteins like IL-2 and GDF11, implicating specific metabolic pathways. The findings highlight a clinical and mechanistic correlation, emphasizing the need for targeted interventions to address these overlapping metabolic pathways in future treatments.

Low HDL cholesterol levels in women and hypertriglyceridemia in men: predictors of MASLD onset in individuals without steatosis

BACKGROUND

Individuals with metabolic-associated steatotic liver disease (MASLD) have a worse prognosis compared to patients without steatosis, and its prevalence is increasing. However, detailed risk factors based on obesity and sex remain unclear. We aimed to investigate the impact of cardiometabolic risk factors (CMRFs) on the risk of MASLD in individuals without pre-existing SLD.

METHODS

SLD was diagnosed by ultrasonography. Non-SLD individuals were followed 65,657 person-years. Incidence rates of MASLD were assessed by Kaplan-Meier analysis. Furthermore, independent factors associated with the development of MASLD were identified using Cox regression analysis, stratified by four groups: obese men, non-obese men, obese women, and non-obese women.

RESULTS

The overall incidence rate of MASLD was 39.3/1,000 person-years. The cumulative incidence was highest in obese men, followed by obese women, non-obese men, and non-obese women. Two or more CMRFs increased the risk of MASLD in all groups. Low HDL cholesterol level was the strongest independent risk factor in both obese and non-obese women and hypertriglyceridemia for both obese and non-obese men. The impact of these CMRFs was stronger in non-obese individuals. (HR [95% CI]: women non-obese 1.9 [1.5-2.4], obese 1.4 [1.1-1.8]; men non-obese 2.3 [1.9-2.9], obese 1.5 [1.2-2.0]).

CONCLUSIONS

Multiple CMRFs are important to MASLD development, regardless of sex and obesity. In this Japanese cohort, low HDL cholesterol in women and hypertriglyceridemia in men were the most significant risk factors, especially among the non-obese group. These findings suggest that sex-specific CMRFs may play a role in the development of MASLD.

Diagnosis of moderate-to-severe hepatic steatosis using deep learning-based automated attenuation measurements on contrast-enhanced CT

PURPOSE

To evaluate the utility of deep learning-based automated attenuation measurements on contrast-enhanced CT (CECT) for diagnosing moderate-to-severe hepatic steatosis (HS), using histology as reference standard.

METHODS

This retrospective study included 3,620 liver donors (2,393 men and 1,227 women; mean age, 31.7 ± 9.4 years), divided into the development (n = 2,714) and test (n = 906) cohorts. Attenuation values of the liver and spleen on CECT were measured both manually and using a deep learning algorithm (before and after radiologists' correction of segmentation errors). Performance of: (1) liver attenuation and (2) liver-spleen attenuation difference for diagnosing moderate-to-severe HS (> 33%) was assessed using the area under the receiver operating characteristic curve (AUC). Three different criteria targeting 95% sensitivity, 95% specificity, and the maximum Youden's index, respectively, for diagnosing moderate-to-severe HS, were developed and validated.

RESULTS

The performance of deep learning-based measurements did not differ significantly, with or without radiologists' corrections (p = 0.13). Liver-spleen attenuation difference outperformed liver attenuation alone in diagnosing moderate-to-severe HS in both deep learning-based (AUC, 0.868 vs. 0.821; p = 0.001) and manual (AUC, 0.871 vs. 0.823; p = 0.001) measurements. In the test cohort, the criterion targeting 95% sensitivity for diagnosing moderate-to-severe HS (liver-spleen attenuation difference ≤ 2.8 HU) yielded 92.0% (69/75) sensitivity and 48.5% (403/831) specificity. The criterion targeting 95% specificity (liver-spleen attenuation difference ≤ -18.8 HU) yielded 53.3% (40/75) sensitivity and 95.7% (795/831) specificity. The criterion targeting the maximum Youden's index (liver-spleen attenuation difference ≤ -8.2 HU) yielded 82.7% (62/75) sensitivity and 80.7% (671/831) specificity.

CONCLUSION

Deep learning-based automated measurements of liver and spleen attenuation on CECT can be used reliably to detect moderate-to-severe HS.

Incremental Value of Blood-Based Markers of Liver Fibrosis in Cardiovascular Risk Stratification

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) with advanced liver fibrosis is associated with cardiovascular disease (CVD).

OBJECTIVE

This work aimed to examine if markers of vascular injury mediate the link between liver fibrosis noninvasive tests (LFNITs) and CVD events, and to compare the incremental predictive value of LFNITs over established CVD risk scores.

METHODS

Consecutively recruited individuals (n = 1692) with or without clinically overt coronary artery disease (CAD) from the Athens Cardiometabolic Cohort, were analyzed. Fibrosis-4 index (FIB-4), NAFLD Fibrosis score (NFS), and BARD score were evaluated for direct and indirect associations with indices of subclinical arterial injury including carotid maximal wall thickness (maxWT) and pulse wave velocity (PWV) and with a composite of major adverse cardiovascular events (MACE) that consisted of cardiac death, acute myocardial infarction, or coronary revascularization (39-month median follow-up).

RESULTS

FIB-4 was the only LFNIT that was consistently associated with multiple markers of vascular injury, irrespective of CAD presence and after controlling for traditional risk factors, surrogates of insulin resistance, or obesity (adjusted P < .05 for all). FIB-4 was also independently associated with CAD presence (adjusted odds ratio [OR] 6.55; 3.48-12.3; P < .001). Increased FIB-4 greater than 2.67 was incrementally associated with an increased risk for MACE (OR [95% CI] 2.00 [1.12-3.55], ΔAUC [95% CI] 0.014 [0.002-0.026]). These associations were mediated by maxWT rather than PWV. Only FIB-4 (>3.25) was independently and incrementally associated with all-cause mortality (adjusted P < 0.05).

CONCLUSION

In a cardiometabolically diverse population, the incremental associations of LFNITs with CVD outcomes were mediated by atherosclerotic burden rather than arterial stiffening. FIB-4 consistently demonstrated associations with all study end points. These findings provide mechanistic insights and support the clinical applicability of FIB-4 in CVD prevention.

Clinical application of bile acid profile combined with lipid indices in metabolic dysfunction-associated steatotic liver disease

OBJECTIVE

This study aims to investigate the diagnostic potential of bile acid profiles combined with lipid parameters in metabolic dysfunction-associated steatotic liver disease (MASLD).

METHOD

This study employed LC-MS technology to analyze the serum bile acid profiles of 186 male patients with MASLD and 80 male non-MASLD patients. According to whether the serum samples exhibit dyslipidemia, the subjects were divided into four groups. Subsequently, a series of analyses were conducted, including univariate analysis, the Spearman correlation test, multinomial logistic regression, restricted cubic spline regression, and ROC curve analysis.

RESULT

The bile acid profiles of serum samples with dyslipidemia exhibit significant differences compared to those of normal serum samples. The bile acids, which include total deoxycholic acid (DCA), secondary bile acids (SBA), unconjugated bile acids (UCBA), 12α-hydroxylated bile acids (12HBA), total bile acids (TBA), primary bile acids (PBA)/SBA, and glycine-conjugated bile acids (GCBA)/taurine-conjugated bile acids (TCBA), demonstrate a non-linear correlation with the logarithmic ratio of triglycerides (TG) to high-density lipoprotein cholesterol (HDL-C). The ROC analysis indicates that, in populations with normal lipid levels, bile acid indicators such as GLCA and 12HBA demonstrate a superior ability to distinguish between MASLD and non-MASLD compared to populations with abnormal lipid levels and the overall population. Their diagnostic performance significantly surpasses that of existing MASLD diagnostic models.

CONCLUSION

The combination of bile acid profiles and lipid indicators holds significant diagnostic potential in MASLD.

Non-linear relationship between triglyceride glucose index and new-onset diabetes among individuals with non-alcoholic fatty liver disease: a cohort study

BACKGROUND

The relationship between the triglyceride glucose (TyG) values and the development of diabetes in non-alcoholic fatty liver disease (NAFLD) patients is not yet well researched. This study aims to examine how the baseline TyG levels correlate with the incidence of new-onset diabetes in this specific cohort.

METHODS

This cohort included 2,506 normoglycemic Japanese adults with NAFLD who underwent routine health check-ups at Murakami Memorial Hospital between 2004 and 2015. Several statistical approaches, including restricted cubic splines and two-piecewise linear regression, were utilized to assess the relation between the TyG levels and diabetes risk.

RESULTS

Among the 2,506 participants (mean age: 44.78 ± 8.32 years; 81.09% male), 203 individuals (8.10%) developed diabetes over the course of the 11-year follow-up period. A U-shaped relationship was observed between the levels of TyG and the onset of diabetes, with an inflection point identified at a TyG value of 7.82 (95% CI: 7.72-8.00). Below this threshold, each one-unit elevation in TyG values reduced the probability of diabetes by 93% (HR = 0.07, 95% CI: 0.01-0.32, P = 0.001). Conversely, above this threshold, each one-unit elevation increased the probability of diabetes by 70% (HR = 1.70, 95% CI: 1.19-2.44, P = 0.004).

CONCLUSIONS

The findings validate a U-shaped association between TyG levels and new-onset diabetes in adults with NAFLD. Both low and high TyG levels increase diabetes probability in such a group.

A research protocol for a prospective, multicenter, cohort study on interferon therapy for chronic hepatitis B combined with metabolism-associated fatty liver disease to achieve clinical cure

Introduction

The incidence of chronic hepatitis B (CHB) combined with metabolism-associated fatty liver disease (MAFLD) is increasing annually, and the presence of MAFLD may influence the clinical assessment of viral activity and transaminase levels. However, it remains unclear whether MAFLD impacts the achievement of clinical cure in CHB patients treated with polyethylene glycol interferon (Peg-IFN).

Methods

A prospective cohort study was conducted to enroll patients with dominant CHB (on NA treatment, HBsAg <1,500 IU/mL, HBeAg negative, HBV DNA <10 IU/mL) and patients with dominant CHB combined with MAFLD, all of whom were treated with Peg-IFN. The study aimed to assess the efficacy and safety of Peg-IFN treatment and to elucidate the effect of MAFLD on achieving HBsAg clearance in these patients. Additionally, the study explored the T-lymphocyte characteristics of patients with CHB combined with MAFLD, analyzed the role of T-lymphocytes expressing inhibitory receptors in HBsAg clearance, and investigated the immunological mechanisms of HBsAg clearance through single-cell transcriptome sequencing technology.

Ethics and dissemination

Patients will be recruited at four medical centers in Beijing and Hebei, and written informed consent will be obtained to inform participants of the purpose of the study, potential risks, and benefits. Ethical approval has been granted for the study, which will focus on 48-week HBsAg clearance, and a detailed follow-up and adverse event monitoring plan has been developed.

Strengths and limitations of this study

Strengths are that this study fills the gap in treatment strategies for patients with CHB combined with MAFLD and provides important treatment guidance to clinicians; the multicenter design may increase the diversity of the sample size, reduce the bias of single-center studies, and improve the external validity of the results. Limitations are that interferon therapy is often associated with side effects, which may lead to lower patient adherence and affect long-term follow-up and outcome monitoring of the study; the heterogeneity of the MAFLD population may have different effects on the efficacy of interferon therapy.

Clinical trial registration

http://www.chictr.org.cn/bin/project/edit?pid=231498, identifier ChiCTR2400084913.

Liver Cirrhosis: ancient disease, new challenge

Liver cirrhosis is a common cause of morbidity and mortality worldwide. Excessive alcohol consumption and metabolic associated steatotic liver disease are the most common etiological factors of cirrhosis in our region. Cirrhosis occurs in two well-differentiated phases, compensated and decompensated, depending on the absence or presence of complications, respectively. Current therapeutic strategies are aimed at controlling these complications (such as ascites, hepatic encephalopathy, bacterial infections, or digestive hemorrhage, among others) or performing a liver transplant if there are no contraindications. However, it is important to eliminate the etiological factor responsible for the disease, as this can lead to the disappearance of complications, a state known as recompensation. This article proposes an updated review of the epidemiology of cirrhosis and its main causes, and offers an overview of the clinical features and treatment of the disease's complications, in addition to outlining future lines of research in this field.

Estimated sdLDL-C as a biomarker of hepatic steatosis severity in MASLD: a retrospective study

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide. However, there is a lack of cost-effective and accurate biomarkers to assess the degree of hepatic steatosis. Estimated small dense low-density lipoprotein cholesterol (EsdLDL-C), a calculated value derived from triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C) levels, has emerged as a potential indicator. This study aimed to explore the relationship between EsdLDL-C and the severity of hepatic steatosis.

METHODS

This single-center retrospective study estimated and directly measured small dense low-density lipoprotein cholesterol (sdLDL-C) in 1,969 patients who underwent serum lipid testing at Changzhou Third People's Hospital between January and July 2024. Among these, 461 patients diagnosed with MASLD were included in the study. These patients were further classified into mild (Mil) and moderate-to-severe (Mod-Sev) groups based on controlled attenuation parameter (CAP) values to explore the relationship between EsdLDL-C and the severity of hepatic steatosis.

RESULTS

The correlation coefficient (R) between EsdLDL-C and DsdLDL-C was 0.837, with a bias of 0.223. Both EsdLDL-C (OR 1.095, 95% CI 1.029-1.180) and visceral fat area (VFA) (OR 1.019, 95% CI 1.010-1.028) were identified as independent risk factors for Mod-Sev steatosis compared to the Mil group. After adjusting for all confounders, patients with MASLD had a 1.155-fold increased risk of developing Mod-Sev hepatic steatosis for each unit increase in EsdLDL-C. Furthermore, EsdLDL-C demonstrated good predictive value for Mod-Sev steatosis in MASLD patients, with an area under the curve (AUC) of 0.825 (95% CI 0.784-0.867).

CONCLUSIONS

EsdLDL-C may serve as a practical and cost-effective biomarker for identifying high-risk MASLD patients.

TRIAL REGISTRATION

The retrospective study was approved by the Ethics Committee of Changzhou Third People's Hospital (02 A-A20230015), and a waiver of informed consent was agreed to, as the data were obtained from medical records, and a waiver of informed consent would not have affected the participants.

Pathogenic Mechanisms of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)-Associated Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer deaths worldwide. The etiology of HCC has now dramatically changed from viral hepatitis to metabolic dysfunction-associated steatotic liver disease (MASLD). The main pathogenesis of MASLD-related HCC is the hepatic lipid accumulation of hepatocytes, which causes chronic inflammation and the subsequent progression of hepatic fibrosis. Chronic hepatic inflammation generates oxidative stress and DNA damage in hepatocytes, which contribute to genomic instability, resulting in the development of HCC. Several metabolic and molecular pathways are also linked to chronic inflammation and HCC in MASLD. In particular, the MAPK and PI3K-Akt-mTOR pathways are upregulated in MASLD, promoting the survival and proliferation of HCC cells. In addition, MASLD has been reported to enhance the development of HCC in patients with chronic viral hepatitis infection. Although there is no approved medication for MASLD besides resmetirom in the USA, there are some preventive strategies for the onset and progression of HCC. Sodium-glucose cotransporter-2 (SGLT2) inhibitor, a class of medications, has been reported to exert anti-tumor effects on HCC by regulating metabolic reprogramming. Moreover, CD34-positive cell transplantation improves hepatic fibrosis by promoting intrahepatic angiogenesis and supplying various growth factors. Furthermore, exercise improves MASLD through an increase in energy consumption as well as changes in chemokines and myokines. In this review, we summarize the recent progress made in the pathogenic mechanisms of MASLD-associated HCC. Furthermore, we introduced new therapeutic strategies for preventing the development of HCC based on the pathogenesis of MASLD.

Liver-derived Neuregulin1α stimulates compensatory pancreatic β cell hyperplasia in insulin resistance

Compensatory pancreatic islet hyperplasia is an adaptive response to increased systemic insulin demand, although factors meditating this response remain poorly understood. Here, we show that a liver-derived secreted protein, Neuregulin1α, promotes compensatory proliferation of pancreatic β cells in type 2 diabetes. Liver Neuregulin1α expression and serum Neuregulin1α levels increase in male mice fed an obesity-inducing diet. Male mice lacking either Neuregulin1 in liver or its receptor, ErbB3, in β cells deteriorate systemic glucose disposal due to impaired β cell expansion with reduced insulin secretion when fed the obesity-inducing diet. Mechanistically, Neuregulin1α activates ERBB2/3-ERK signaling to stimulate β cell proliferation without altering glucose-stimulated insulin secretion potential. In patients with metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity but without type 2 diabetes serum Neuregulin1α levels increase, while in patient with MASLD and type 2 diabetes show markedly reduced levels of Neuregulin1α. These results suggest that Neuregulin1α serves as a hepatokine that can expand functional β cell mass in type 2 diabetes.

Overexpression and biophysical and functional characterization of a recombinant FGF21

Fibroblast growth factor 21 (FGF21) is an endocrine FGF that plays a vital role in regulating essential metabolic pathways. FGF21 increases glucose uptake by cells, promotes fatty acid oxidation, reduces blood glucose levels, and alleviates metabolic diseases. However, detailed studies on its stability and biophysical characteristics have not been reported. Herein, we present the overexpression, biophysical characterization, and metabolic activity of a soluble recombinant FGF21 (rFGF21). The far-UV circular dichroism spectra of rFGF21 show a negative trough at 215 nm, indicating that the protein's backbone predominantly adopts a β sheet conformation. rFGF21 shows intrinsic tyrosine fluorescence at 305 nm. Thermal denaturation using differential scanning calorimetry reveals that rFGF21 is relatively thermally unstable, with a melting temperature of 46.8°C (±0.1°C). The urea-induced unfolding of rFGF21 is rapid, with a chemical transition midpoint of 0.4 M. rFGF21 is readily cleaved by trypsin in limited trypsin digestion assays. Isothermal titration calorimetry experiments show that rFGF21 does not bind to heparin. Interestingly, rFGF21 demonstrates proliferative activity in NIH/3T3 fibroblasts and enhances mitochondrial oxidative phosphorylation and fatty acid oxidation in 3T3-L1 adipocytes. These findings provide a crucial framework for the engineering of novel structure-based variants of FGF21 with improved stability and biological activity to treat metabolic disorders.

Effect of high-intensity interval training on clinical parameters in patients with metabolic dysfunction-associated steatotic liver disease: a systematic review and meta-analysis of randomized controlled trials

High-intensity interval training (HIIT) has potential health benefits in the treatment of many chronic diseases. However, the efficacy of HIIT in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) remains unclear. This systematic review and meta-analysis aimed to assess the impact of HIIT on intrahepatic lipids (IHLs) , liver enzymes, and metabolic profiles in individuals with MASLD. All randomized-controlled trials (RCT) that evaluated and compared the effects of HIIT on clinical parameters in patients with MASLD were searched using the PubMed, EMBASE, WOS, and Cochrane databases. Data analysis and integration were performed using RevMan 5.3 (Cochrane Collaboration, Copenhagen, Denmark) and Stata version 18 software (StataCorp LLC, College Station, Texas, USA), and outcomes were assessed using the standardized mean difference (SMD). Our results showed that compared with other types of exercise or no exercise, HIIT could reduce the levels of IHL [SMD: -0.56%, 95% confidence interval (CI): -0.99 to -0.13, P = 0.01], BMI (SMD: -0.31, 95% CI: -0.62 to -0.01, P = 0.04), alanine aminotransferase (ALT) (SMD: -0.61, 95% CI: -0.95 to -0.26, P = 0.0006), and aspartate aminotransaminase (AST) (SMD: -0.43, 95% CI: -0.81 to -0.05, P = 0.03) in patients with MASLD. In addition, subgroup analyses showed that HIIT had a positive impact on clinical indicators in patients with MASLD with an intervention duration of less than equal to 8 weeks. This study supports the idea that HIIT can significantly reduce IHL, BMI, ALT, and AST levels, and further studies are needed to assess the long-term adherence and treatment effects of HIIT.

Metabolic dysfunction-associated steatotic liver disease in adults

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the umbrella term that comprises metabolic dysfunction-associated steatotic liver, or isolated hepatic steatosis, through to metabolic dysfunction-associated steatohepatitis, the progressive necroinflammatory disease form that can progress to fibrosis, cirrhosis and hepatocellular carcinoma. MASLD is estimated to affect more than one-third of adults worldwide. MASLD is closely associated with insulin resistance, obesity, gut microbial dysbiosis and genetic risk factors. The obesity epidemic and the growing prevalence of type 2 diabetes mellitus greatly contribute to the increasing burden of MASLD. The treatment and prevention of major metabolic comorbidities such as type 2 diabetes mellitus and obesity will probably slow the growth of MASLD. In 2023, the field decided on a new nomenclature and agreed on a set of research and action priorities, and in 2024, the US FDA approved the first drug, resmetirom, for the treatment of non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced fibrosis. Reliable, validated biomarkers that can replace histology for patient selection and primary end points in MASH trials will greatly accelerate the drug development process. Additionally, noninvasive tests that can reliably determine treatment response or predict response to therapy are warranted. Sustained efforts are required to combat the burden of MASLD by tackling metabolic risk factors, improving risk stratification and linkage to care, and increasing access to therapeutic agents and non-pharmaceutical interventions.